Pt C.A, 81 years old, white, male, complaining of three episodes of emesis, preceded by nausea in the last 2 days, decreased appetite., headache, and chills. Since this morning patient is feeling very sick, and weak after he is having frequent episodes of voluminous, watery diarrhea, (5 episodes) no mucus, no blood and comes with abdominal discomfort, cramping, and blooding. 101F fever is constated at the office, HR 122 , ta 100/70 mmhg, RR 22

Pt has a history of benign prostatic hypertrophy, and he was treated for a urinary tract infection treated with ciprofloxacin for 10 days last month.

Another detail can be fabricated.

Pt history

Diabetes type 2, last A1c 6.2,
Compensate diabetes continues with glimepiride 1mg after breakfast. Metformin 500 mg 40 minutes after breakfast and dinner.
HTN controlled: continue losartan 100mg 1tablet daily after breakfast.
Hyperlipidemia: Atorvastatin 20 mg tab PO 1 tablet daily.
Vit D deficiency. Vit D 50,000 U weekly for 4 weeks, them Vit D 1000U weekly OTC.

Dx acute bacterial gastroenteritis is secondary to Clostridiodes difficile infection. (An older patient who’s presenting with fever, has a white [blood cell] count and has more than 3 diarrheal stools in 24 hours, this kind of patient will fit into the picture of a diagnosis of C diff.) help to support main diagnosis. You should include more details here to support the Dx.

Diferencial DX to be included.
Acute gastroenteritis secondary to the food-borne pathogen.
IBS
Diarrhea antibiotic associate.

Treatment.
Fluid repletion — The most critical therapy in diarrheal illness is rehydration, preferably by the oral route. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may meet the fluid and salt needs in patients with mild illness.
The electrolyte concentrations of fluids used for sweat replacement (eg, Gatorade) are not equivalent to oral rehydration solutions, although they may be sufficient for the otherwise healthy patient with diarrhea who is not hypovolemic.
Encourage increased fluid intake of 1.5 to 2.5 liters/24 hours plus 200 ml for each loose stool restrict the intake of caffeine, milk, and dairy products.
Encourage the client to eat foods rich in potassium.
As the patient is anorectic and has nausea and vomiting, a short period of consuming only liquids will not be harmful.
Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are indicated in patients with watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be consumed.
Foods with high-fat content should be avoided until the gut function returns to normal after a severe bout of diarrhea.
Trimethoprim-sulfamethoxazole 480 mg BID for 5 days.
Stool culture was taken at the office. Order for a Blood test (CBC, Fasting blood sugar, )
Basic information please organize it and add more.

With this patient in mind, address the following in a SOAP Note using the Template provided
• Subjective: What details did the patient provide regarding her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic (very important to include med, dose, frequency and duration) and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan (provide scholarly references for your rationale).
• Reflection notes: What would you do differently (if anything) in a similar patient evaluation? Don’t forget this section-you will lose 10 points if omitted.
Helpful Hints:
• Keep in mind that It needs to be an acute visit on an adult patient with a HEENT complaint
• Follow the SOAP Note template provided – but please be sure to delete the information included which gives you a description of the section and fill in with your findings.

• Keep in mind that this is a graduate-level academic assignment, so please don’t use any unacceptable abbreviations and support your work with current scholarly references (< 5 years old).
• At this level in your course, you are required to write at a graduate level using APA format, which includes, but not limited to title page, running head, headers, double spacing, and references. Resources for APA are given under your course resources.

Use the following template.
Episodic/Focus Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT: etc.).
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
A.
Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
P.
Includes documentation of diagnostic studies that will be obtained,
referrals to other health care providers,
therapeutic interventions,
education,
disposition of the patient and any planned follow up visits.
Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?
Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).
References
You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Use this and other you can provide.
Akhondi H, Simonsen KA. Bacterial Diarrhea. [Updated 2022 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551643/

Stokely JN, Niendorf S, Taube S, Hoehne M, Young VB, Rogers MA, Wobus CE. Prevalence of human norovirus and Clostridium difficile coinfections in adult hospitalized patients. Clin Epidemiol. 2016 Jun 28;8:253-60. doi: 10.2147/CLEP.S106495. PMID: 27418856; PMCID: PMC4934455.